Methods and apparatus for monitoring the cardiovascular condition of patients with sleep disordered breathing

ABSTRACT

A method for relating to each other cardiovascular and sleep disordered breathing conditions of a patient. The patient&#39;s heart rate and/or detailed echocardiogram data is monitored and recorded continuously or periodically together with sleep disordered breathing information on similar time scales. Changes in the patient&#39;s heart rate associated with changes in sleep disordered breathing can then be observed. More specifically, positive airway pressure at therapeutic levels for treatment of sleep disordered breathing is applied while events associated with the treatment of the patient&#39;s sleep disordered breathing are detected and recorded. At the same time, information concerning the cardiovascular condition of the patient is stored and the stored information concerning the cardiovascular condition of the patient and the recorded events associated with the treatment of the patient&#39;s sleep disordered breathing are related to each other.

This application is a continuation of Ser. No. 10/598,914, now allowed,which is a National Stage Entry of PCT/US05/10663 filed Mar. 30, 2005which claims the benefit of U.S. provisional application No. 60/557,846filed on Mar. 31, 2004.

FIELD OF THE INVENTION

This invention relates to methods and apparatus for treating andmonitoring sleep disordered breathing (“SDB”) in patients withcardiovascular disease or otherwise monitoring the cardiovascularcondition of SDB patients.

BACKGROUND OF THE INVENTION

“Sleep-disordered breathing” generally refers to types of breathingdisruption that occur during sleep. The most common form of sleepdisordered breathing is obstructive sleep apnea (“OSA”). OSA affectsapproximately 20 million Americans—as many as asthma or diabetes. Lessthan 10% of people with OSA have been diagnosed and fewer have beentreated. Loud, intermittent snoring, apneas, and hypopneascharacterize—OSA. Because the symptoms of sleep apnea present themselvesas a result of a precursor, SDB has become the general term used todescribe any disease state that manifests apneas and/or hypopneas duringsleep. Apneas and hypopneas interfere with gas exchange, fragment sleep,and frequently cause oxygen desaturations. In severe cases, patients mayexperience these oxygen desaturations and arousals from sleep hundredsof times each night.

The most common treatment of SDB is to administer continuous positiveairway pressure (CPAP). The use of nasal CPAP to treat OSA was inventedby Sullivan and taught in U.S. Pat. No. 4,944,310. Briefly stated, CPAPtreatment acts as a pneumatic splint of the airway by the provision of apositive pressure, usually in the range 4-20 cm H₂O. The air is suppliedto the airway by a motor driven blower that is coupled via an airdelivery hose to a nose (or nose and/or mouth) mask sealed with thepatient's face. More sophisticated forms of CPAP treatment may beprovided by bi-level ventilators, proportional assist ventilators andservo-controlled ventilators. Such devices are typically used by thepatient on a daily basis before and during sleep.

For example, nasal CPAP treatment of OSA may involve the use of anautomated blower, such as the AUTOSET T™ device or AUTOSET SPIRIT™available from ResMed Ltd. Examples of suitable nasal CPAP masks are theMIRAGE™ nasal mask and the MIRAGE™ full face mask also available fromResMed Ltd. The AUTOSET T™ device continuously monitors the state of thepatient's airway and determines an appropriate pressure to treat thepatient, increasing it or decreasing it as necessary. Alternatively,bi-level pressures are delivered to the patient as in the VPAP II™devices also available from ResMed Ltd. Some of the principles behindthe operation of the AUTOSET T™ and VPAP II™ devices are described inU.S. Pat. No. 5,704,345. The entire disclosure of U.S. Pat. No.5,704,345 is incorporated herein by reference. Other forms of pressuretreatment are available such as that which is delivered in accordancewith a smooth pressure waveform template and a continuous phase variableto provide comfortable pressure support substantially in phase with thepatient's respiratory cycle. The device is the subject of U.S. Pat. No.6,532,957, the entire disclosure of which is hereby incorporated byreference.

In May 2000, a study in the New England Journal of Medicine indicated aprofound link between SDB and hypertension, independent of otherrelevant risk factors. Hypertension as a disease has been estimated toafflict more than 25% of the population over 44 years of age. Leftuntreated, it leads to cardiovascular diseases such as heart attacks,stroke, coronary artery disease and heart failure. Collectively,cardiovascular disease (“CVD”) is now recognized as the major cause ofdeath and disability in modern societies. Studies have shown that over60% of stroke, 50% of heart failure, 35% of hypertensive and 30% ofcoronary artery disease patients have SDB.

In general, CVDs are diseases that have an impact on the correctfunctioning of the heart and blood vessels. In addition tocerebrovascular diseases (stroke), other significant CVDs includemyocardial infarction (heart attack), congestive heart failure (“CHF”),transient ischaemic attacks (“TIA”) and peripheral vascular diseases, toname a few. As a whole it has been estimated that about 17 millionpeople die of CVDs annually. Early diagnosis and treatment of CVDs canbe a major factor in reducing mortality associated with CVDs.

CPAP devices have in the past been used for the treatment of SDB in CVDpatients. In one such device a form of pressure treatment has beendirected at treatment of cardiac failure and Cheyne-Stokes breathing. Ina device designated AUTOSET CS™, also provided by ResMed Ltd., pressuresupport is varied in phase with patient respiration in such a manner tooppose the waxing and waning changes in patient respiration thatcharacterize Cheyne-Stokes breathing. The device is the subject of U.S.Pat. No. 6,532,959, the entire disclosure of which is incorporatedherein by reference.

As disclosed by Farrell et al. in U.S. Pat. No. 6,336,454, CPAPtreatment has also been recognized as a beneficial treatment of stroke.The use of CPAP treats stroke patients by improving arterial bloodoxygen levels and reducing arterial carbon dioxide levels as well asimproving auto-regulation of, for example, blood pressure, cardiacoutput and ventilation. Improvements in morbidity, such as rate anddegree of recovery of vital signs and patient stabilization in the acutephase, is an expected benefit.

Also, U.S. Pat. No. 5,794,615 teaches a system including methods andapparatus for treatment of congestive heart failure. The system involvesapplying separate and independent gains to flow rates of pressurized gasdelivered to a patient during inspiratory and expiratory phases of arespiratory cycle. The pressure support is disclosed as reducing cardiacpre-load and after load.

In short, there are many devices that can be used for treating SDB inpatients that have cardiovascular disease. Nevertheless, despite arecognized need for early treatment or diagnosis of CVD patients and alack of complete understanding of the mechanics of these diseases,little has been done to take advantage of the patient informationmonitoring potential of such CPAP devices that would exploit thesubstantial presence of these devices in the lives of SDB patients whomay also be CVD patients or potential CVD patients. In short, thereexists a need to track or monitor information related to such patientsthat would promote early treatment and diagnosis of CVD as well asfurther the understanding of SDB.

SUMMARY OF THE INVENTION

It is an objective of the invention to provide methods and apparatus fortreating respiratory disorders in cardiovascular disease patients orpotential cardiovascular disease patients.

It is a further objective to provide methods and apparatus that assistin the management or monitoring of the cardiovascular condition of suchpatients to assist with diagnosis or treatment of related diseases.

Other objectives will be apparent to those skilled in the art from areview of the description of the invention as contained herein.

In accordance with one aspect of the invention there is providedapparatus comprising a sleep disordered breathing treatment unit and aunit for monitoring the patient for indications of cardiovasculardisease.

The invention provides methods and apparatus useful for cardiovasculardisease patients or potential cardiovascular disease patients with sleepdisordered breathing. Preferably, the device is capable of deliveringpositive airway pressure at therapeutic levels for treatment of sleepdisordered breathing. The device can be configured with one or moreprotocols that may be utilized in the provision of such pressuretreatment. Over the course of one or more sessions of such treatment,the device may be configured to detect and record events associated withsleep disordered breathing, such as apnea, hypopneas, partialobstruction, snoring, pressure versus time, flow versus time, and leakfor future analysis.

Additionally, the device is configured to detect or prompt and accept asinput additional information concerning the cardiovascular condition ofthe patient including, for example, blood pressure, heart rate, oximetrydata, electrocardiogram data, Holter Analysis results (includingarrhythmia and heart-rate variability summaries), body mass index(including height and weight data), Left Ventricular Ejection Fraction(“LVEF”), six-minute walk data, B-type natriuretic peptide (“BNP”),cardiac output data, VO2 max data, New York Heart Association Class(“NYHA”), ACC/AHA Heart Failure Stage, Quality of Life data (including,for example, Epworth Sleepiness Scale, Berlin Questionnaire, MinnesotaLiving with Heart Failure Questionnaire, and Kansas City CardiomyopathyQuestionnaire), peripheral arterial tone (“PAT”), and Key neuro-hormonallevels (e.g., catecholamine levels).

Such data may be continuously or periodically recorded or entered intothe device relative to time. With such data in the device associationsmay be observed or made between the cardiovascular information and sleepdisordered breathing related events on a common time scale so thatchanges that occur approximately or substantially in common may beobserved or tracked. Such data may be retrieved from or viewed on thedevice or accessed remotely by a physician or clinician for purposes ofmonitoring or diagnosis of the patient's SDB and/or a potential CVD.

Another aspect of the invention is a combination of products, servicesand business pathways for providing care of SDB and CVD co-morbidpatients.

Other aspects of the invention are described in the following detaileddescription.

BRIEF DESCRIPTION OF DRAWINGS

FIG. 1 shows an apparatus according to the invention; and

FIG. 2 is a flow chart of a method for monitoring patient cardiovascularinformation.

FIGS. 3 & 4 are flow charts showing business pathways in accordance withaspects of the invention.

DESCRIPTION OF THE INVENTION

With reference to FIG. 1, the invention involves a pressure deliverydevice that may include a servo-controlled blower 2, a mask 6, and anair delivery conduit 8 for connection between the blower 2 and the mask6. Exhaust gas is vented via exhaust 13. Optionally, a flow sensor 4 fand/or pressure sensor 4 p may also be utilized in which case mask flowmay be measured using a pneumotachograph and differential pressuretransducer or similar device to derive a flow signal F(t), and maskpressure is measured at a pressure tap using a pressure transducer toderive a pressure signal P_(mask)(t). The pressure sensor 4 f and flowsensor 4 p have only been shown symbolically in FIG. 1 since it isunderstood that those skilled in the art would understand how to measureflow and pressure. Flow F(t) and pressure P_(mask)(t) signals are sentto a controller or microprocessor 15 to derive a pressure request signalP_(request)(t). P Alternatively, a flow signal f(t) and pressure signalP_(mask)(t) may be estimated or calculated in relation to the blowermotor by monitoring current supplied to the motor and/or the speed ofthe motor as disclosed in U.S. Pat. Nos. 5,740,795, 6,332,463 or6,237,593 without the provision of flow and pressure sensors asdescribed above. Optionally, the blower motor speed may be heldgenerally constant and pressure changes in the mask may be implementedby controlling an opening of a servo-valve that may variably divert/ventor deliver airflow to the mask.

A controller 15 or processor is configured and adapted to implement themethodology described in more detail herein and may include integratedchips, a memory and/or other instruction or data storage medium. Forexample, programmed instructions with the control methodology may becoded on integrated chips in the memory of the device or suchinstructions may be loaded as software. With such a controller, theapparatus can be used for many different pressure treatment therapiessimply by adjusting the pressure delivery equation that is used to setthe speed of the blower or to manipulate the venting with the releasevalve.

The apparatus preferably also includes a communication port or module10, for example, a wireless communication transceiver and/or a networkcard, for communication with other devices or computers such ashand-held display and control devices 12. The apparatus may furtherinclude additional interface 16 for connection to additional diagnosisor patient information gathering devices. For example, a diagnosis unitmay optionally include a pulse oximeter 20, respiratory movement sensors22 such as a chest band, EEG & ECG 24, EOG 25 and/or electrodes 28 fordetecting cardiac rhythm. The oximeter may optionally be included in themain blower housing. There is a sense tube 14 connected to the mainhousing of the blower to the mask that allows the apparatus to senseoxygen concentration and pressure levels in the mask 6. Optionally, anautomated PCO₂ measurement device 21 or other non-invasive blood gasmonitor/device for measuring PCO₂ may be linked to provide an input datasignal to the microprocessor 16, for example, a device as taught in U.S.Pat. No. 5,630,413, the disclosure of which is incorporated byreference. Other automated measuring devices may also be included withthe diagnosis unit as it relates to measuring other cardiovascularrelated information from the patient. In this regard, the device may,for example, be configured to communicate/receive such information fromits own display (e.g., LCD screen) and input device (e.g., keypad orbuttons) or via telemetry or other communication link from a bloodpressure monitor, heart rate monitor, oximetry monitor, ECG device, ECGEvent Monitor, Holter monitor, automated tape measure, automated weightscale, treadmill device, blood analyzer device, cardiac output analyzerdevice, VO₂ max data device or peripheral arterial tone assessmentdevice. Those skilled in the art will recognize the types of informationthat may be generated by such devices.

Other optional input and/or output devices 22 may be included to displayoutput signals and enter input signals for the microprocessor 16.Various appropriate input and output devices such as keypads and displayscreens and other alternatives are known in the art.

While this apparatus is generally described as a single unit, it isunderstood that a combination of devices and/or computers linked by anyavailable communications method may be used to accomplish the goals ofthe invention. For example, the apparatus can interface with a varietyof hand-held devices such as a Palm Pilot via wireless communication orit may interface with a network for transmission between the devices.With such a device or system, a physician may, for example, remotelymonitor, analyze or record the status or data history of a patient. Forexample, remote devices may send to or retrieve from the apparatus anydesired cardiovascular or other information. Such information may evenbe transmitted from the apparatus to a database of one or more patients.Furthermore, the treatment program that is being run on the patient canbe monitored and changed remotely. In the event patient data istransmitted over open networks, the data may be encrypted for purposesof patient confidentiality.

Pressure Treatment Protocols

As illustrated by step 42 in the flow chart of FIG. 2, the apparatusincorporates various pressure treatment protocols that may be used totreat the condition of the patient. For example, in one mode, the deviceprovides a generally constant pressure throughout a breathing cycle thatmay be therapeutic pressure or changes to such pressure set to treatSDB. In another mode, the apparatus provides a higher pressure to themask during the inspiratory portion of the breathing cycle, a so-calledIPAP (inspiratory positive airway pressure), and a lower pressure to themask during the expiratory portion of the breathing cycle, a so-calledEPAP (expiratory positive airway pressure). Alternatively, the treatmentdelivered by the apparatus can smoothly vary in accordance with patientrespiration to provide a smooth pressure waveform. For example, thedevice calculates a continuous phase variable to provide support inphase with the patient's breathing cycle and calculates the pressure tobe delivered in accordance with a pressure waveform template. Thedelivery of such pressure is disclosed in U.S. Pat. No. 6,532,957. Stillalternatively, pressure may be supplied in proportion to patientrespiratory airflow.

In yet another form, pressure support is varied in phase with patientrespiration in such a manner to oppose the waxing and waning changes inpatient respiration that characterize Cheyne-Stokes breathing. Themethodology for such treatment is disclosed in U.S. Pat. No. 6,532,959.

Optionally, the therapeutic pressure levels of the above protocols maybe preset by a clinician or may be automatically adjusted or set byautomatic detection of SDB related events, such as apneas (obstructiveor central), hypopneas, partial obstruction, snoring, etc. as disclosedin U.S. Pat. No. 5,704,345 (Berthon-Jones). For example, the IPAP orEPAP levels may be adjusted by the automated determination to hunt for aminimal pressure that will be required to prevent or alleviateobstruction. Other alternative methods to vary the therapeutic level ofthe pressure for treatment to a patient and to detect SDB events may beutilized and are known in the art.

In providing these treatment methodologies, an accurate determination ofrespiratory airflow is important. Thus, the determined flow rate of airto the patient may be adjusted to account for the effect of leak. Tothis end, leak airflow may be determined by using a method such astaught in U.S. Pat. No. 6,152,129 (Berthon-Jones), the entire disclosureof which is incorporated herein by reference. Leak data may also berecorded over time and stored in the device. Other known methods fordetermining leak may also be used by the device.

Other forms of pressure treatment will be known to those skilled in theart and may be implemented by the device.

Monitoring of Sleep Disordered Breathing Related Information

Preferably, the device provides efficacy tracking by detecting andrecording or scoring SDB events or related information or indicesovertime, for example, by tracking or detecting central apneas,obstructive apneas, hypopneas, partial obstructions (e.g., flowflattening) or snoring. This is illustrated in step 44 of FIG. 2.Similarly, pressure and/or flow versus time data may also be recordedfor analysis. In so doing, the device preferably performs compliancetracking in which the time on and time off of the mask are recorded withSDB related events for evaluation by statistical summaries and charting.Methods for detecting and recording such information are known in theart, and may be implemented as described in U.S. Pat. No. 5,704,345.

For example, the device may record AHI (apnea hypopnea index) over timeor during particular time periods such as session-by-session,day-by-day, hour-by-hour, etc. In one embodiment of the invention an AHIscoring scheme may be implemented as follows:

-   -   (i) An apnea is scored if a 2 second moving average ventilation        drops below 25% of a recent average ventilation (time        constant=100 s) for at least 10 consecutive seconds,    -   (ii) An hypopnea is scored if the 8 second moving average drops        below 50% but not more than 25% of the recent average        ventilation for 10 consecutive seconds.        Similarly, the device may determine an index comparing central        apneas versus obstructive apneas as disclosed in U.S. Pat. No.        6,832,609, the entire disclosure of which is incorporated by        reference herein.

These events may be recorded with the time they occur or added to atotal for a particular time period. Those skilled in the art willrecognize other methods or modifications for detecting sleep disorderedbreathing information such as hypopneas or apneas and determining an AHIover time or within time periods.

Monitoring of Cardiovascular Condition

As previously noted and illustrated in step 40 of FIG. 2, the device isconfigured to receive information relating to cardiovascular informationfor the patient. Thus, a device of the invention preferably includesinput devices for receiving or recording such based on the condition ofthe patient, continuously or periodically, so that preferably, asillustrated in step 46 of FIG. 2, such information may be associatedwith changes in the sleep disordered breathing related information overtime. Embodiments of the invention may include automated measuringapparatus that can generate signals associated with the automaticallydetermined cardiovascular information for a processor of the device.Alternatively, the device may be pre-programmed to prompt or query forsuch information on a display or from another remote device, before useand/or periodically such as monthly, after three or six months, or someother timed period which may be based on use of the device (e.g., after30 nights of use, etc.), so that such information may be measured ordetermined separately and input by a user on a keypad or other dataentry device. In relation to cardiovascular related questionnaires,queries may be pre-programmed into the device and appropriate responsescan be input by the patient in response to prompting by the device.

In one embodiment, an apparatus of the invention may include automatedblood pressure monitoring apparatus that may continuously orperiodically monitor or measure blood pressure and record suchinformation such as in an overnight summary versus time. Alternatively,the device may prompt for input of such information on a display andkeypad without the provision of such an automated device. Suchinformation may then be charted alone or in association with sleepdisordered breathing related information or events, such as an AHI, on acomparable or similar time scale so that related changes may be observedor noted.

In one embodiment, the device may monitor and record heart rate and/ordetailed echocardiogram data continuously or periodically. Suchinformation may be detected by filtering cardiogenic flow from arespiratory flow signal as disclosed in U.S. Pat. No. 5,704,345 or byanother available heart rate detector. By recording such informationover time, alone or on a similar time scale as sleep disorderedbreathing information, changes in heart rate may be observed orassociated with changes in sleep disordered breathing to assist intracking the condition of the patient.

Similarly, various embodiments of the device may optionally measure,prompt for and/or record/monitor additional cardiovascular informationincluding oximetry data, blood sugar data, blood pressure data,electrocardiogram data, Holter Analysis results (including, e.g.,arrhythmia, heart-rate and/or variability summaries), Body Mass Index,height and weight data, Left Ventricular Ejection Fraction (LVEF),Six-minute walk data, B-type natriuretic peptide (BNP), Cardiac Outputdata, VO2 max data, New York Heart Association Class (NYHA), ACC/AHAHeart Failure Stage, Quality of Life data (including, e.g., EpworthSleepiness Scale, Berlin Questionnaire, Minnesota Living with HeartFailure Questionnaire, and/or Kansas City Cardiomyopathy Questionnaire),Peripheral arterial tone (PAT) and Key neuro-hormonal levels (e.g.,catecholamine levels).

Depending on the patient using the device, some or all of theabove-listed cardiovascular information may be monitored by the device.In this regard, the device may be configured to monitor all of thisinformation but the physician can preset the device to select one ormore of the features for particular patients, which will then bemonitored during their use. In one embodiment, the device ispre-programmed with associated sets or groups of data selected from thecardiovascular information that are pertinent for specificcardiovascular patients. By selecting a particular patient type, thedevice can automatically be configured to monitor the pertinentcardiovascular information from the associated set or group of monitoreddata without monitoring unnecessary cardiovascular information for theparticular patient. For example, a hypertension patient may be monitoredfor blood pressure, heart rate and Body Mass Index or a heart failurepatient may be monitored for LVEF1 heart rate and cardiac output data, adiabetic may be monitored for blood sugar, etc. Those skilled in the artwill understand which cardiovascular information is preferablyassociated with the different types of cardiovascular patients.

With the collection of such cardiovascular information being managed bythe pressure treatment device, for example, on a night-by-night orweek-by-week basis as it relates to the particular information beingcollected, a physician or clinician may periodically access asubstantial source of information for study or analysis, as illustratedby step 48 of FIG. 2. Preferably, the cardiovascular and SDB informationmay be periodically remotely transferred to the physician or it may beaccessed directly through displays on the device. In this way, aphysician may keep up with and observe the changing cardiovascularcondition of the patient with minimal direct oversight or intervention.Optionally, the device can be programmed with thresholds for comparisonto the recorded cardiovascular information to trigger an alarm or send amessage or generate a warning for the user, clinician or physicianeither directly on the device, or remotely, for example, over a secureelectronic network to a database. For example, if the recorded ordetected heart rate falls below an acceptable level, a warning or alarmmay be generated. Similarly, if changes in weight, arrhythmia, bloodpressure, blood sugar, heart variability, ECG data, etc. are recorded,automated warnings, alarms or messages may be generated by the deviceand manual or automated changes to the control of the device may be madesuch as a change in treatment protocol or a change to the set ofmonitored cardiovascular information such that additional cardiovascularinformation may be monitored. For example, the device may switch frommonitoring hypertension associated cardiovascular information tomonitoring congestive heart failure associated cardiovascularinformation if changes in the hypertension related monitoring datasuggest that the patient's cardiovascular condition is deteriorating.Similarly, the device's treatment protocol may switch from a standardbi-level protocol to one that delivers servo-controlled pressure changesintended to reduce waxing and waning changes associated withCheyne-Stokes breathing.

Monitoring patients is an important aspect of management ofcardiovascular disease. In accordance with an embodiment of theinvention, one can take advantage of the long-term use of nasal CPAPdevices (almost every night for the rest of the patient's life) tomonitor patients for many years. Thus it is hoped that early detectioncan lead to improved outcomes of a patient.

While the invention has been described with various alternativeembodiments and features, it is to be understood that the embodimentsand features are merely illustrative of the principles of the invention.Those skilled in the art would understand that other variations can bemade without departing with the spirit and scope of the invention. Forexample, cardiovascular related treatment or diagnostic devices may beimplemented to query for or measure SDB related information for thepurpose of detecting SDB or otherwise determining a relationship betweenthe cardiovascular condition of the patient and SDB. For example, aHolter Monitor or cardiac event monitor may be configured or programmedto prompt a patient with an SDB questionnaire. Thus, in one embodiment,the device may prompt a user with such questions as:

1. Do you snore?

2. Are you excessively tired during the day?

3. Do you wake during the night feeling breathless?

4. Have you been told you stop breathing during sleep?

5. Do you have a history of hypertension?

In response to the answers from the user input into the device, forexample, if yes to two or more of these questions is received, thedevice may record, transmit or generate a warning to the user orphysician to consider referral to a clinician or other physician for thepurpose of undertaking a sleep diagnostic study to access the potentialfor SDB. In a more complex embodiment, a more detailed assessment of SDBrelated information may be implemented by the device. For example, itmay prompt for the following:

Gender: (Male or Female)

Age Group: 18-39 40-59 60-79 80+

Height: (feet, inches)

Weight: (pounds)

1. Do you snore regularly?

2. Are you excessively sleepy during the day?

3. Do you wake during the night feeling breathless?

4. Have you been told you stop breathing during sleep?

5. Do wake up feeling un-refreshed after a night's sleep?

6. Do you have a history of hypertension?

7. Is the patients BMI>30?

The number of positive responses may be tallied by the device togenerate a SDB index which may be reported to a physician with a warningor other message. Alternatively, the SDB index may be compared to one ormore thresholds and the degree of the need for a follow-up SDB study maybe contained in a message or warning to the physician or user. Forexample, if the tally is 1 or 0, the message may identify that there isa low likeliho A higher tally, such as a 4 or higher, may result in amore significant or urgent warning message suggesting that there is ahigh or higher likelihood of SDB or a need for a full SDB assessment.Such data may be combined with other sleep disordered breathing datarecorded by the device, for example, an AHI, if the device is configuredto record such data and may be included in the message or warning to thephysician or user.

Similarly, other cardiovascular related treatment or diagnostic devicemay be configured or programmed to make an assessment for SDB relatedinformation of the patient, for example, a blood pressure monitor, heartrate monitor, oximetry monitor, Holter Monitor or other ECG device orcardiac event monitor, automated tape measure, automated scale devicefor weight, treadmill device, blood analyzer device, cardiac outputanalyzer device, VO2 max data device, peripheral arterial tone deviceetc.

It should be appreciated that clinicians interested in SDB and thoseinterested in cardiovascular and even other diseases do not usuallycross lines and engage in each others' disciplines. The data collectedduring treatment of SDB can go back many years. This data can be minedand can be used by clinicians interested in other diseases, even withoutrelating such data to events associated with the patient's SDB, yetpresently the data is generally not even made available. It is ourintention that the data collected over the long term (measured by atleast several months) during treatment of SDB will be made available toclinicians treating one or more other diseases that the patients mayhave. By charging for such data, it is expected that some of the costsassociated with treatment of SDB may even be recoverable. (By“clinicians” we include hospitals, insurance companies and othersinterested in studying data pertaining to patient diseases.)

Business Pathways

FIGS. 3 & 4 show business pathways in accordance with the invention.Such pathways can be adopted by organisations caring for SBD and CVDco-morbid patients using the equipment shown in FIG. 1. The pathwaysidentify steps to be taken, and identifies the appropriatere-imbursement codes. The pathways can be programmed into portablecomputers, such as PALM PILOT handheld computers, providing thepractitioner with a ready reference for the appropriate codes, as wellas allowing a highly skilled medical practitioner (such as acardiologist) to delegate responsibility to their staff.

For example, in accordance with FIG. 3, in a first step a cardiologypatient is given a questionnaire programmed into a handheld computer asdiscussed above. A positive result from the questionnaire prompts thedevice to suggest an unattended sleep study, for example with a Holtermonitor, as well as reimbursement codes 95806 and 93230. After the sleepstudy, the results are entered into the computer. A high AHI from thesleep study indicates the potential presence of Obstructive Sleep Apnea(OSA) or Central Sleep Apnea (CSA). Patients with OSA may be treatedwith an Automatic Positive Airway Pressure (APAP) device such asResMed's AUTOSET SPIRIT. Alternatively, patients with CSA may be treatedwith ResMed's VPAP III ST/A device, or Adaptive Servo Ventilation, suchas provided by ResMed's AutoSet CS2 device.

In one branch of the flowchart, the decision process includes oximetryor OSA screening by a device such as ResMed's APNEA LINK.

While the invention has been described in several forms, it is to beunderstood that these forms are merely illustrative of the invention.Those skilled in the art will understand that other variations can bemade without departing with the spirit and scope of the invention.

1-25. (canceled)
 26. An apparatus for adjusting delivery of treatmentfor sleep disordered breathing to a patient comprising: a positiveairway pressure delivery device for continuously delivering therapeuticlevels of pressurized air, a detector for detecting patient breathingand events associated with the patient's sleep disordered breathing, amonitor for monitoring at least one parameter regarding thecardiovascular condition of said patient, a storage medium for storingdata regarding the breathing and cardiovascular condition of the patientand the delivered pressurized air over time, and a processor foradjusting delivery of positive airway pressure based onbreathing-associated detected events as well as patient breathing andcardiovascular condition changes over time.
 27. The apparatus of claim26 wherein said monitor monitors the patient's heart rate.
 28. Theapparatus of claim 27 wherein said monitor is a Holter monitor.
 29. Theapparatus of claim 26 wherein said monitor is an echocardiogram monitor.30. The apparatus of claim 26 wherein said breathing-associated detectedevents include at least one of apneas, hypopneas, partial obstructions,snoring, pressure versus time, flow versus time, and leaks.
 31. Theapparatus of claim 26 wherein the stored data include at least one ormore of blood pressure, heart rate, oximetry data, electrocardiogramdata, Holter analysis results, body mass index, left ventricularejection fraction (LVEF), cardiac output data, and VO₂ max data.
 32. Theapparatus of claim 26 wherein said monitor is an oximeter.
 33. Apressurized air delivery apparatus for relating a patient'scardiovascular and sleep disordered breathing conditions to each other,comprising: a cardiovascular condition monitor for monitoring andrecording the cardiovascular condition of a patient continuously orperiodically, a detector for detecting patient breathing and relatedevents associated with the treatment of the patient's sleep disorderedbreathing over time, a respiratory therapy delivery device for providinga patient with respiratory therapy, and a processor (1) for analyzingdetected patient breathing and sleep disordered breathing treatment onsimilar time scales, (2) for correlating changes in the patient'scardiovascular condition with changes in sleep disordered breathing andtreatment, and (3) for adjusting the delivered therapy treatment. 34.The apparatus of claim 33 wherein said monitor monitors the patient'sheart rate.
 35. The apparatus of claim 34 wherein said monitor is aHolter monitor.
 36. The apparatus of claim 33 wherein said monitor is anechocardiogram monitor.
 37. The apparatus of claim 34 wherein said sleepdisordered breathing-associated events include at least one of apneas,hypopneas, partial obstructions, snoring, pressure versus time, flowversus time, and leaks.
 38. The apparatus of claim 33 wherein saidmonitor records at least one or more of blood pressure, heart rate,oximetry data, electrocardiogram data, Holter analysis results, bodymass index, LVEF, cardiac output data, and VO₂ max data.
 39. Theapparatus of claim 33 wherein said monitor is an oximeter.
 40. Anapparatus for delivering respiratory therapy to a patient suffering fromsleep disordered breathing, comprising: an adjustable pressure deliverydevice, a detector for detecting patient breathing over time and eventsassociated with the patient's sleep disordered breathing, a monitor forcollecting a patient's cardiovascular condition data over time, and aprocessor for automatically adjusting the pressure delivered by saidpressure delivery device based on analyzing responses to a questionnaireregarding the patient's condition, said collected cardiovascularcondition data, and said detected breathing events.
 41. The apparatus ofclaim 40 wherein said monitor monitors the patient's heart rate.
 42. Theapparatus of claim 41 wherein said monitor is a Holter monitor.
 43. Theapparatus of claim 40 wherein said monitor is an echocardiogram monitor.44. The apparatus of claim 40 wherein said sleep disordered breathingevents include at least one of apneas, partial obstructions, snoring,pressure versus time, flow versus time, and leaks.
 45. The apparatus ofclaim 40 wherein the collected data include at least one of one or moreof blood pressure, heart rate, oximetry data, electrocardiogram data,Holter analysis results, body mass index, LVEF, cardiac output data, andVO₂ max data.
 46. The apparatus of claim 40 wherein said monitor is anoximeter.